Cigarette Smoking Is Caused By A Delusion, Redux

I leaned back in my chair and breathed a heavy sigh. My patient, Mr. Rodriguez (not his real name), noticed my discomfort. "I know I should quit," he told me with a guilty shrug of his shoulders.

"Have you ever tried?" I asked.

"Once," he replied, "but it didn't stick."

Mr. Rodriguez had been a pack-a-day smoker for the past 20 years, something he'd only begrudgingly confessed in response to a standard inquiry I make of all my first time patients. He didn't see it as a problem himself. Or at least he hadn't mentioned it when I'd asked him at the beginning of the visit why he'd come to see me.

"Are you aware of all the ways cigarette smoking is bad for you?" I asked. An alarmingly high proportion of patients know surprisingly little about all the potential consequences of tobacco smoking. Mr. Rodriguez, however, was able to come up with two of the major ones: heart attacks and lung cancer. "Why do you keep smoking when you know it causes heart attacks and lung cancer?" I asked him. He shrugged, obviously embarrassed to be caught in a contradiction. But even as I tried to shame him into wanting to quit by preying on his need to appear consistent, I knew no contradiction actually existed.

Wisdom, Nichiren Buddhism argues, is the key ingredient to achieving happiness. And wisdom, rather than knowledge, is what my patient, Mr. Rodriguez, seemed so desperately lacking. He knew intellectually he shouldn't smoke, but that knowledge hadn't yet penetrated to become wisdom—to become, in essence, action. Despite his embarrassment, Mr. Rodriguez presented no contradiction because action never arises from knowledge alone. It arises from knowledge that is believed. How often do we understand with our intellects how we ought to behave but find ourselves unable to do so? Why, for example, do some people know how to set appropriate boundaries with others, but other people can't bring themselves to say no to anyone? Why do some alcoholics figure out they need to stop drinking and stop, while others state they know they should, but never do? Why do some people hear advice to quit smoking and quit that very day, while others smoke on even after heart attacks and strokes?

The answer lies not just in what we believe but also in the degree to which we believe it. Deeply held belief—Buddhism (and psychology) would argue—introduces a critical ingredient necessary for change: motivation. One of my patients tried and failed to quit smoking for several years until his wife casually mentioned one day how much she hated coming home to a smoke-filled house, and he stopped for good the next day. He'd finally discovered the motivation to quit: a sudden, burgeoning awareness (that is, a deeply felt belief) of the harm his smoking was doing not to himself but to his wife. He was ultimately more capable of believing that his wife's life was at risk than he was his own. Not surprising when you consider most of us tend to deny the possibility of our own death far more vigorously than we deny the possibility of everyone else's.

HOW EFFECTIVE IS A DOCTOR'S ADVICE?

"How many of your patients actually quit because you tell them they should?" Mr. Rodriguez wanted to know after I told him my other patient's story. In fact, one meta-analysis tells us on average only 2 out of every 100 smokers told by their physicians to quit will succeed in establishing long-term abstinence. It's less clear how many alcoholics or drug addicts who recognize they're addicted and need to quit actually do. But the principle remains the same: some people can digest intellectual knowledge and translate it into deep and motivating belief, belief they must change their behavior despite all the obstacles—and some simply can't. Specifically, with regard to smokers, 98 out of every 100 can't.

What, then, is the difference between those two smokers who hear their physicians' warnings about the dangers of smoking and for the first time truly understand it's time for them to quit and the other 98 who agree they should quit, who may even want to quit, but repeatedly fail in their attempts? Why did the possibility of losing his wife motivate one of my patients but not Mr. Rodriguez? Or asked from a Buddhist perspective, why do some find the wisdom and others do not?

One could argue that Mr. Rodriguez did in fact believe in the dangers of nicotine, both to himself and his wife, but that he was simply too addicted to succeed in quitting. I would argue, however, the problem lay less with the strength of his addiction and more with the weakness of his belief. If those dangers, which he only weakly believed applied to himself, could have in some way been brought home to him—as Ebeneezer Scrooge's impending death was brought home to him by the Ghost of Christmas-Yet-To-Come showing him his own tombstone—I'm convinced Mr. Rodriguez would have been able to resist the pleasure smoking provided and managed the pain of withdrawal abstention would have produced. Nichiren Buddhism argues that the true reason for the emergence in the human mind of new and powerfully motivating belief is unknowable and therefore unpredictable, which is why I teach residents and students to ignore the odds and counsel all of their smoking patients to quit each and every time they see them. Despite our preconceived expectations that most of our patients won't be able to listen, clearly we have no way of predicting which 2 out of every 100 will.

I would argue, therefore, there are two possible approaches to the practice of medicine and that the second of the two is better. The first involves diligently providing appropriate advice about smoking cessation, abstention from alcohol for those who abuse it, or pharmacological management of depression and anxiety (to name only a few of the common ailments that affect my patient population).

The second approach, however, involves becoming interested in the beliefs patients hold that keep them trapped in harmful behavior patterns. It involves embracing a view of the human mind that recognizes all behavior arises out of belief and that if we could only help patients find their way to wisdom, their lives might then become governed by actions that lead to happiness and joy rather than pain and suffering. This, then, is how I view the proper role of a physician: not just as an advocate for patients' health but for their happiness as well. While I certainly don't believe I have all the wisdom my patients would ever need to solve every problem they face, I am equally certain they do themselves.

My ultimate aim, then, and, it turns out, the most enjoyable part of my day, involves encouraging patients to challenge their deeply held beliefs that, in my view, obstruct their ability to change maladaptive behaviors. Though I often fail, I am never able to predict with whom I will succeed, so I approach every patient as a mystery to be solved, always full of hope. And as he left my office that morning no more determined to become a non-smoker than when he'd first entered, I wondered: what do you need to hear, Mr. Rodriguez? What experience will cause some critical piece of wisdom to penetrate into your heart and somehow motivate you to save your own life?

Dr. Lickerman's new book The Undefeated Mind: On the Science of Constructing an Indestructible Self is available now. Please read the sample chapter and visit Amazon or Barnes & Noble to order your copy today!

They have created a fear that is based on nothing’’
World-renowned pulmonologist, president of the prestigious Research Institute Necker for the last decade, Professor Philippe Even, now retired, tells us that he’s convinced of the absence of harm from passive smoking. A shocking interview.

What do the studies on passive smoking tell us?

PHILIPPE EVEN. There are about a hundred studies on the issue. First surprise: 40% of them claim a total absence of harmful effects of passive smoking on health. The remaining 60% estimate that the cancer risk is multiplied by 0.02 for the most optimistic and by 0.15 for the more pessimistic … compared to a risk multiplied by 10 or 20 for active smoking! It is therefore negligible. Clearly, the harm is either nonexistent, or it is extremely low.

It is an indisputable scientific fact. Anti-tobacco associations report 3 000-6 000 deaths per year in France ...

I am curious to know their sources. No study has ever produced such a result.

Many experts argue that passive smoking is also responsible for cardiovascular disease and other asthma attacks. Not you?

They don’t base it on any solid scientific evidence. Take the case of cardiovascular diseases: the four main causes are obesity, high cholesterol, hypertension and diabetes. To determine whether passive smoking is an aggravating factor, there should be a study on people who have none of these four symptoms. But this was never done. Regarding chronic bronchitis, although the role of active smoking is undeniable, that of passive smoking is yet to be proven. For asthma, it is indeed a contributing factor ... but not greater than pollen!

The purpose of the ban on smoking in public places, however, was to protect non-smokers. It was thus based on nothing?

Absolutely nothing! The psychosis began with the publication of a report by the IARC, International Agency for Research on Cancer, which depends on the WHO (Editor's note: World Health Organization). The report released in 2002 says it is now proven that passive smoking carries serious health risks, but without showing the evidence. Where are the data? What was the methodology? It's everything but a scientific approach. It was creating fear that is not based on anything.

Why would anti-tobacco organizations wave a threat that does not exist?
...

The anti-smoking campaigns and higher cigarette prices having failed, they had to find a new way to lower the number of smokers. By waving the threat of passive smoking, they found a tool that really works: social pressure. In good faith, non-smokers felt in danger and started to stand up against smokers. As a result, passive smoking has become a public health problem, paving the way for the Evin Law and the decree banning smoking in public places. The cause may be good, but I do not think it is good to legislate on a lie. And the worst part is that it does not work: since the entry into force of the decree, cigarette sales are rising again.

Why not speak up earlier?

As a civil servant, dean of the largest medical faculty in France, I was held to confidentiality. If I had deviated from official positions, I would have had to pay the consequences. Today, I am a free man.